The following describes key elements of the health care reform
legislation that affect employers
The legislation includes the following bills:
the Patient Protection and Affordable Care Act (PPACA, HR
3590), passed March 21 by Congress (and signed into law by
President Obama March 23; and
the Health Care and Education Reconciliation Act of 2010 (HR
4872), passed by the House on March 21 and sent to the
As noted above, PPACA became law on March 23 but only when
HR 4872 was enacted.
Group Market Reforms
Preserving and Expanding Coverage
Health Insurance Market Reforms
Grandfathered Plan Rules
Collectively Bargained Plans
The following provisions are effective for
plan years beginning on or after September
23, 2010, unless otherwise indicated.
No Lifetime Limits
A plan may not apply lifetime dollar limits on what are known as
“essential health benefits.”
Essential health benefits are the types of benefits that must be
included in health plans offered under the state insurance
clearinghouses referred to in the new law as “exchanges.
Health and Human Services (“HHS”) will define what constitutes an
essential health benefit.
No Annual Limits
A plan may not apply any annual dollar limits on
essential health benefits for plan years beginning on or
after January 1, 2014.
For plan years beginning prior to January 2014, some
restricted annual limits may apply to essential health
benefits, if those limits would not violate other federal
or state laws.
Prohibition on Rescissions of Coverage
A plan must not rescind coverage once a participant has
become covered, unless the individual has performed an
act or practice that constitutes fraud, or has made an
intentional misrepresentation of material fact, “as
prohibited by the terms of the plan.”
In addition, it appears that a plan, or a participant’s
coverage under a plan may not be cancelled except with
prior notice to the participant.
Even where a participant has engaged in fraud – such as
by lying about a claim, or trying to gain coverage for an
individual by wrongly asserting that she or he is the
employee’s spouse or dependent – the participant may
be retroactively removed as a participant only if the plan
language so provides.
A plan must provide coverage for, and may not impose
any cost-sharing requirements with respect to, certain
preventative care, including recommended
The statute refers to particular lists of
recommendations and guidelines for determining
which preventative services are subject to this
prohibition on cost-sharing.
Dependent Coverage for Older Children
A plan that provides dependent coverage of children
must continue to make that coverage available for an
adult child until the child turns 26 years of age.
This requirement applies even to married children.
Plans are not required to make coverage available for a
child of a child receiving dependent coverage (that is,
for example, for a grandchild of a participant).
Uniform Explanation of Coverage
HHS is required to develop standards for plans to use in summarizing
plan benefits and coverage for participants.
These standards are supposed to be developed by March 23, 2011.
The required summaries will be a short “highlights” description of the
It must not exceed 4 pages in length and must not include print
smaller than 12-point font.
The statute describes the information that must be covered by the
Plans will have until March 23, 2012, to begin using these new
Deadline for Summaries of Material Modification
A notice of any material modification be given to
participants at least 60 days prior to the date the plan
modification is to become effective.
This provision is generally effective for plan years
beginning on or after September 23, 2010.
Penalty for Failure to Provide New Summary or
A penalty of not more than $1,000 may apply for each
willful failure to provide the required plan summary or
advance summary of a material modification.
Each participant who fails to receive a required
summary (or summary of material modification) is
counted separately in determining the amount of the
penalty, so it appears that a willful failure to timely
provide 5 participants with a summary could result in a
fine of up to $5,000.
The new law requires HHS to promulgate regulations
providing for the development of standardized
definitions of terms used in insured plans.
The required four-page plan summary previously must
include these definitions, to enable participants to
better understand and compare coverage.
The terms for which standardized definitions are to be
developed include the following.
Prohibition on Insured Plans Discriminating in Favor
of Highly Compensated Individuals
Self-insured health plans have long been subject to
nondiscrimination rules prohibiting them from favoring
highly compensated individuals.
Those rules are set forth in Code § 105(h).
The consequence of a self-insured plan failing to meet those
requirements is that reimbursements are included into
income of the highly compensated individuals.
There will be no adverse tax consequence for highly
compensated individuals, of insured plans though there
may be for the employer.
These provisions are subject to the grandfather rules.
Additional Reporting Requirement: Quality of Care
By March 23, 2012, HHS will develop requirements for plans
to report on a variety of issues.
This reporting is to include information relating to:
▪ improving health outcomes through “quality reporting,” effective
case management, care coordination, chronic disease
management, and medication and care compliance initiatives,
▪ activities to prevent hospital readmissions (including through
education and counseling),
▪ activities to improve patient safety and reduce medical errors
through use of best clinical practices, evidence based medicine,
and health information technology, and
▪ wellness and health promotion activities.
Cost Reporting and Limit on Insurers’ Profits
Insurers (not plans) will, with respect to each plan year, be required
to submit to HHS a report concerning loss ratios and expenses,
including the percentage of total premium revenue expended on
reimbursement for clinical services, activities that improve health
care quality, and non-claims costs other than taxes, licensing, or
In addition, the new law effectively caps insurers’ profit margins on
health insurance, beginning no later than January 1, 2011.
It does so by requiring that insurers provide rebates to participants
if the insurers’ premium revenues spent on reimbursement for
clinical services and activities that improve health care quality are
less than 85 % in the large group market, or 80% in the small group
market, of the total amount of premium revenue (excluding taxes,
licensing, and regulatory fees, as well as certain other payments).
States may, by regulation, set a higher percentage than the 85 or
80% figures above.
A new claims appeals process has been added.
Plans will be required to have an external review
Plans must provide participants with notice, in a
culturally and linguistically appropriate manner, of the
available internal and external appeals processes.
A plan must allow a participant to review his or her
file, present evidence and testimony as part of the
appeals process, and, very importantly, receive
continued coverage pending outcome of the appeals
Choice of Health Care Professional
If a plan provides for designation by a participant or
beneficiary of a participating primary care provider,
the plan must permit a participant or beneficiary to
designate any participating primary care provider
who is available to accept that individual.
If a plan provides or covers any benefits with respect to services
in an emergency department of a hospital, the plan must cover
emergency services without requiring prior authorization and
must provide coverage whether or not the health care provider
is a participating provider under the plan with respect to those
A plan must provide for such coverage by a nonparticipating
provider without imposing limitations on coverage more
restrictive than those applicable to emergency department
services from providers who have a contractual relationship
with the plan.
If emergency services are provided out-of-network, the cost-
sharing requirement (expressed as co-payment amount or co-
insurance rate) must be the same as if the services were
If a plan requires, or provides for, the designation of a
participating primary care provider for the child of a
participant or beneficiary, the plan must permit the
designation of a physician (allopathic or osteopathic)
who specializes in pediatrics as the child’s primary care
provider, if the provider participates in the plan’s
This does not, however, require a plan to waive any
coverage exclusions under the terms of the plan
relating to the coverage of pediatric care.
Obstetrical and Gynecological Care
A plan that provides coverage for obstetric or
gynecology care and requires the designation of a
participating primary care provider may not require
authorization or referral by the plan or any person
(including a primary care provider) in the case of a
female participant or beneficiary who seeks coverage
for obstetrical or gynecological care provided by a
participating health care professional who specializes
in obstetrics or gynecology.
Monitoring Insurers’ Premium Increases
HHS, in conjunction with the states, is required to
establish an annual review process, beginning with
the 2010 plan year, for “unreasonable” increases in
premiums for insured plans.
Under this process, an insurer is to be required to
submit a justification for any unreasonable premium
increase prior to implementation of that increase.
Starting with plan years beginning in 2014, the
Secretary of HHS, in conjunction with the states, is to
monitor premium increases, whether reasonable or
The following provisions became effective on
March 23, 2010.
No “Dumping” of Participants
▪ HHS to establish a temporary high risk health insurance
pool program for persons with pre-existing conditions
who have not had creditable coverage for at least six
▪ This pool is to be established no later than June 21, 2010.
▪ The pool is temporary because it will, for the most part,
cease operation on January 1, 2014, when eligibility for
coverage should be better available under other of the
Reinsurance for Early Retirees
HHS is to establish a temporary reinsurance program to
reimburse employer health plans for a portion of their cost of
providing health coverage to early retirees (ages 55 to 64 and
This program is to be established no later than June 21,2010.
Participating plans to submit reimbursement claims and
receive 80% reimbursement of costs between $15,000 and
$90,000 for a covered individual,
Reimbursements can only be used to reduce plan and retiree
direct costs, and
Program capped at $5 billion.
The following provisions are effective for plan years beginning
on or after January 1, 2014.
A plan may not impose any pre-existing condition exclusion.
This will be the case whether or not an individual has prior creditable
coverage and whether or not the individual is a late enrollee.
Although this rule is generally not effective until plan years beginning
on or after January 1, 2014, it is effective earlier for participants (and
apparently dependents) who are under age 19.
For those individuals the rule is effective for plan years beginning on
or after September 23, 2010. This presumably means the rules apply
early to an individual who is under age 19 on the first day of the first
plan year beginning on or after September 23, 2010.
Guaranteed Availability of Coverage
In general, insurers offering coverage in a group
market in a state must accept every employer in that
state that applies for coverage.
The insurer may, though, restrict enrollment to open or
special enrollment periods, so long as it establishes
special enrollment periods for COBRA qualifying events.
Guaranteed Renewability of Coverage
Insurers offering coverage in the group market must
renew or continue in force coverage at the option of the
A new set of rules governing wellness programs.
Rules are similar to those set forth in current HIPAA
current regulations (Participation and standard based
programs), but with refinements.
HIPAA wellness program incentive limit will increase
from 20% to 30% of total cost of coverage.
The reward limit may be increased to 50% of the cost
of coverage if deemed appropriate.
Insurers will be limited in the annual cost-sharing they
may impose under a group health plan.
For plan years beginning in 2014, a plan must not impose
cost-sharing in excess of the maximum out-of pocket
amount in effect for high deductible health plans for
For 2015 and later years, the maximum is subject to
“Cost-sharing” includes (1) deductibles, coinsurance,
copayments, or similar charges, and (2) any other
expenditure required by a participant for a qualified
medical expense with respect to essential health benefits
covered under the plan.
A plan must not apply a waiting period that exceeds
Certain rules do not apply to “grandfathered plans,” or at
least do not apply to certain participants in those plans.
The general rule for grandfathered plans is that the
requirements grouped together above under the headings
“Group Health Reforms” and “Health Insurance Market
Reforms” do not apply to a plan’s coverage of an individual
if that individual was enrolled in the plan on March 23,
In addition, the rules do not apply to family members of
such a grandfathered individual who are permitted to enroll
after March 23, 2010, if the enrollment of those family
members was permitted under the terms of the plan as in
effect on March 23, 2010, and the plan is “renewed” after
March 23, 2010.
Further, a plan that provided coverage on March 23,
2010, may permit “new” employees (and their family
members) to enroll in the plan without having the
provisions of the law described to this point in the
newsletter apply to those new employees (and their
There are a number of exceptions to the general rule
that the provisions grouped together above under the
headings “Group Health Reforms” and “Health
Insurance Market Reforms” do not apply to
The following rules apply to grandfather plans:
The rules requiring insured plans to issue a standard
plan summary (the four page “highlights”
description) and use standardized definitions in that
The rules requiring insured and self-insured plans
to distribute summaries of material modifications 60
days in advance of any material change, apply to
grandfathered plans for plan years beginning on or
after March 23, 2010.
The following provisions also apply to grandfathered
plans, and will do so at the same time they would apply
to non-grandfathered plans:
The waiting period rules,
The restrictions on lifetime and annual limits,
The rules on rescission,
The pre-existing condition prohibition, and
The rules on covering adult children (up to age 26) as
dependents, although for plan years beginning before January 1,
2014, the rules will apply only to an adult child who is not
eligible to enroll in an “eligible employer-sponsored health plan”
other than the grandfathered plan.
▪ For coverage maintained under a collective
bargaining agreement (CBA) ratified before
March 23, 2010, all new coverage and cost-
sharing rules apply on the termination date
of the last CBA relating to the coverage.
▪ Any coverage amendment to a CBA to
comply with these rules will not be treated
as terminating the CBA.
Large employers must provide coverage to
their full-time employees or pay a financial
This mandate applies beginning January 1,
2014 (technically, it applies for months
beginning after December 31, 2013).
An employer is large if it employed an average of at least 50
full-time employees on business days during the preceding
There is, however, an exception where (1) the employer’s
workforce exceeds 50 full-time employees for 120 days or fewer
during the calendar year, and (2) the employees in excess of 50
employed during the 120 day period were seasonal workers.
An employer must count not only its full-time employees for a
month, but must add to that a number of full-time employees
determined by dividing the aggregate number of hours of service
of employees who are not full-time employees for the month by
In determining an employer’s size, companies will be
aggregated as a single employer under the Tax
Code’s control group and similar aggregation rules.
A full-time employee for this purpose is one who is
employed on average at least 30 hours of service per
HHS, in consultation with DOL, is to prescribe
guidance for determining an employee’s number of
hours of service, including rules for employees not
compensated on an hourly basis.
There are two scenarios in which a large employer
may be required to pay a penalty (in the form of a
nondeductible excise tax).
First, it will be liable for a penalty if:
it fails to offer its full-time employees (and their dependents)
the opportunity to enroll in “minimum essential coverage”
under an “eligible employer-sponsored plan” for any month,
at least one full-time employee has been certified to the
employer as having enrolled for that month in a qualified
health plan with respect to which the employee is entitled to a
premium tax credit or cost-sharing reduction.
In this event, the employer must pay an amount for the month equal to
the product of:
the “applicable payment amount,” and
the number of full-time employees employed by the employer during
the month, reduced by 30 employees.
The “applicable payment amount” means, with respect to any month,
1/12th of $2,000 (or $166.67).
For calendar years after 2014, this dollar amount, and the other employer
penalties described below, will be increased to the extent appropriate
under an indexing scheme described in the new law.
The second way in which a large employer may be assessed a
payment is where:
it offers its full-time employees (and their dependents) the
opportunity to enroll in minimum essential coverage under an
eligible employer-sponsored plan for a month, but
(b) one or more full-time employees has been certified to the
employer as having enrolled for that month in a qualified health
plan with respect to which the individual is entitled to a premium
tax credit or cost-sharing reduction.
In that event, the employer must pay an amount, but only for those
full-time employees enrolled in a qualified health plan who were
allowed a premium tax credit or cost-sharing reduction.
The penalty for the month will equal the product of:
the number of the employer’s full-time employees in a qualified health
plan who are entitled to a premium tax credit or cost-sharing reduction,
1/12th of $3,000 (or $250).
There is an overall limit on the aggregate amount of tax for any month for
which the employer offers the opportunity to enroll in minimum essential
That overall limit is the product of (a) the “applicable payment amount”
(1/12th of $2,000), and (b) the number of individuals employed by the
employer as full-time employees during
the month, reduced by 30 employees.
A large employer to avoid an excise tax under the employer
mandate, it must offer full-time employees (and their
dependents) the opportunity to enroll in “minimum essential
coverage” (and it cannot have any full-time employees
purchasing qualified health plans who receive a premium tax
credit or cost-sharing reduction).
An employer must offer “affordable” health coverage to all its
full-time employees (and their dependents), and the plan
must be structured so participants do not pay more than 40
percent of covered claims costs.
For this purpose, coverage will be considered affordable only
if an employee’s premium is no more than 9.5% of the
employee’s household income.
If a large employer fails to offer all its full-time
employees affordable coverage under a plan
bearing at least 60% of the cost of covered claims,
the employer will likely need to pay an excise tax.
An employer must pay an excise tax if any of its
full-time employees purchases health insurance
through the new insurance clearinghouses to be
set up by the states (that is, the “exchanges”) and
the employee receives a premium tax credit or
cost-sharing credit from the government in that
An employer with more than 200 full-time employees
that offers employees enrollment in one or more
health benefit plans must automatically enroll new
full-time employees in one of those plans (subject to
any permissible waiting period) and continue the
enrollment of current employees.
Employees must be provided with adequate notice of
this automatic enrollment program and of the
employees’ opportunity to opt out of coverage in
which they were automatically enrolled.
The effective date of this requirement is unclear.
New employer notice requirements informing
employees of the following:
Information about the state Exchanges,
If plan’s share of total allowed costs of benefits is less
Availability of a tax credit.
Availability of free choice vouchers, and
Notice must be provided March 1, 2013 or upon
Employer reporting to enforce individual
Must report whether employees were offered
coverage, length of waiting period, lowest cost
option, actuarial value, etc.
Secretary has the authority to review for accuracy,
particularly the amount of the large employer’s share
of the total allowed costs under the plan (presumably
for purpose of determining whether the plan had an
actuarial value of more or less than 60%).
Effective beginning January 1, 2014.
Reporting Cost of Health Coverage on W-2
Effective for years beginning after December 31,
2010, an employer must report on an employee’s
W-2 the aggregate cost of the employee’s health
insurance coverage sponsored by the employer,
excluding the amount of any salary reduction
contribution to a flexible spending arrangement.
Employers must offer vouchers to employees with
household incomes at or below 400% of the federal
poverty level (FPL) if their contribution for
employer-sponsored coverage would be 8% to 9.5%
of household income:
Voucher amount equal to highest (percentage) employer
contribution to any of its own plans.
Vouchers provided for purchasing exchange-based
coverage but employees could keep any excess
Excise tax on high-cost coverage
Starting in 2018, 40% excise tax applies to value of
coverage exceeding $10,200/single, $27,500/family:
Stand-alone dental and vision plan coverage is not subject
to the excise tax.
Higher thresholds for retirees and workers in high-risk
professions ($11,850 and $30,950) and for multiemployer
Thresholds adjusted for age and gender.
Thresholds indexed to:
CPI plus 1% in 2018 - 2019.
CPI in 2020 and later years.
Medicare Part D
Discounts on brand-name drugs,
Means-test for Part D premiums, and
Phases in competitive bidding to base Medicare
Advantage benchmarks on actual plan costs.
Medicare Part D tax change starting in 2013, and
Eliminates Medicare Part D donut hole, beginning
with $250 rebate in 2010.
Starting in 2013, Medicare payroll tax of 2.35% on
employees whose annual earnings exceed $200,000
(individual) or $250,000 (couple); no change in 1.45%
Medicare tax for others.
Group health plan fees for federal comparative
effectiveness research trust fund.
Excise tax on indoor tanning services.
Fees on health insurers, pharmaceutical
manufacturers and medical device manufacturers.
Other tax increases
Starting in 2013, 3.8% tax on capital gains, interest,
dividends and other net investment income for
taxpayers with adjusted gross income exceeding
$200,000 (individual) or $250,000 (couple).
HSAs, Health FSAs and Health Reimbursement
Starting in 2011, tougher coverage/contribution limits
and penalties apply:
No tax-free coverage for nonprescribed items, and
Higher penalty for nonqualified HSA distributions, from 10% to
Starting in 2013 Health FSA contribution $2,500.
Tax-free employer coverage for children who are
not otherwise tax dependents
Tax-free treatment for adult children who have not
turned age 27 as of end of year.
This change is also intended to apply to the exclusion
for employer-provided coverage (that is, the value of
coverage) under an accident or health plan for injuries
or sickness for such a child.
Penalty calculated as lesser of these amounts:
National average premium for the year, or
A percentage of income (up to 2.5% in 2016), or
$325 in 2015, $695 in 2016 and indexed thereafter.
For a COMPLIMENTARY/NO OBLIGATION analysis of
your organizations employee benefits plan, please
Forest Financial Group, Inc.
1650 W. 45th Ave, Suite B
Munster, IN 46321
Or by email:
Information provided by:
Attorney at Law